In 2007, Salam Fayyad accepted the dual post of finance minister and prime minister in the Palestinian Authority (PA). The financial management practices he implemented during his first period as finance minister, from 2002 to 2004, had deteriorated. During the preceding two years, from November 2005 to March 2007, the government had resumed dealing largely in cash, had kept poor records of government financial transactions, and had added more employees to an already bloated public payroll. To reinstitute good practices and implement new reforms, Fayyad and his finance ministry colleagues also had to overcome challenges related to the division of the Palestinian territories into two separate areas governed by competing political parties. Fayyad relied heavily on a small group of trusted staff, delegated important responsibilities so he could also take on the demanding job of prime minister, and set clear guidelines to maximize the long-term benefits from any external technical assistance the ministry hired.  Under his guidance, the ministry rehabilitated financial records and quickly created a new financial information system by adapting existing, locally built software; reformed the way the PA used commercial bank accounts to conduct its financial transactions; and filled gaps in capacity.  

Tristan Dreisbach and staff drafted this case study based on multiple conversations with Salam Fayyad in Princeton, New Jersey, during 2019, as well as other interviews conducted in Ramallah, Nablus, Jericho, and Washington, D.C. the same year.  The case is part of a series on state building in Palestine in 2002–05 and 2007–11. Case published June 2022.

“Could the Palestinian Authority survive?” That was the question on many Palestinians’ minds when Salam Fayyad became finance minister in June 2002 and the cash-strapped government was struggling to pay its civil servants and suppliers. To avert a collapse, Fayyad quickly took steps to increase government revenue. He developed a system that would direct into a single, centralized treasury account all taxes, fees, and other income collected by government offices. He created a fund that consolidated the Palestinian Authority’s tangled and largely opaque commercial and investment assets and contracted with an outside firm to conduct a full audit of those holdings. He also took action to reduce smuggling and assert control over the tobacco authority and petroleum commission—two autonomous PA agencies plagued with management problems. The reforms required Fayyad to navigate political resistance and an entrenched administrative culture wary of financial transparency. Fayyad’s achievements enhanced efficiency, helped restart the flow of tax revenues withheld by Israel, and enabled the PA to attract external support and investment, quashing—at least temporarily—an existential financial crisis.

Tristan Dreisbach drafted this case study based on a series of interviews conducted with Salam Fayyad in Princeton, New Jersey, in 2019. The study also incorporates other interviews conducted in the Palestinian cities of Ramallah, Nablus, and Jericho in June and July 2019. The case is part of a series on state building in Palestine, 2002–05 and 2007–11. Case published March 2022.

During the first decade and a half after Nigeria returned to democracy in 1999, the country struggled to adequately fund its primary health care system. Despite a nearly 10-fold increase in the size of the economy, Nigeria in 2014 was still spending only US$11 per capita on health care—equal to only 6% of total government expenditure and far below regional norms and the nation’s own stated aspiration. As a result, Nigerian citizens were paying 69% of their medical expenses out of pocket, and the cost discouraged many from seeking treatment. A new National Health Act, adopted in 2014 after a decade of delay, raised hopes for a solution by stipulating that at least 1% of the government budget go into a new fund to improve basic services provided at the thousands of primary health care clinics located throughout the country. However, owing to Nigeria’s longstanding neglect of primary health care, there was a real risk that the fund might never become reality. To demonstrate the viability of the program and press for its implementation, the federal health ministry, led by Minister Isaac Adewole, developed operational procedures that spelled out crucial steps to ensure financial accountability and transparency, won international backing for a pilot project that would validate the system, and built a support coalition that spanned the government and civil society. The effort took three years, but in 2018 the Nigerian legislature passed an appropriations bill that for the first time included the 1% allocation for the fund—significantly boosting the resources available to improve the quality and accessibility of primary health care services across Nigeria. Even more significantly, in September 2019, the government declared the fund a statutory allocation that it would automatically renew every year, and clinics in three states began receiving the new resources in November 2019.

Leon Schreiber drafted this case study based on interviews conducted in Abuja, Nigeria, in July and August 2019 with the help of Bunmi Otegbade. Case published November 2019.

In 2005, Vietnam’s legislature voted to develop a new health insurance system that would reduce most citizens’ out-of-pocket health-care costs and instructed the health ministry to take steps to make care more accessible, more affordable, and more effective—especially for those who lived in remote, mountainous regions. One of the challenges was how to manage scarce resources in order to constrain soaring costs. Another was how to coordinate with provinces and local governments (districts and communes)—which controlled much of the country’s health-care spending—in order to achieve national priorities, such as improved preventive care. During the next several years, the health ministry’s Department of Planning and Finance worked with those subnational units to improve the financial information system, hone strategies and plans, and align activities. By 2014, Vietnam’s government had more than tripled its per-capita health-care spending—to US$48.82 in 2014 from US$15.52 per capita in 2005, in current US dollars—a rate of growth that outpaced the average in both low-income and lower-middle-income countries. Although the ministry still struggled to keep patients’ costs down, the share of out-of-pocket spending fell to 45% in 2015 from 67% in 2005, according to government figures.

ISS staff members drafted this case study based on interviews conducted in Hanoi, Vietnam by Simon Engler and Huong Dang in May, June, and August 2018. Case published in May 2019. This case is part of an ISS series on linking health priorities to the budget process.

Ethiopia’s Federal Ministry of Health was struggling to meet its goals in 2014 despite impressive gains in the health of its citizens during the previous 20 years. A new minister and his leadership team reached out for ideas by engaging Ethiopia’s regions, districts, and communities—an essential step in a large and ethnically diverse society. They then developed an ambitious transformation program to help realize the government’s national aspirations for health care, including commitments made to achieving the Millennium Development Goals. To bring their vision to fruition, however, the minister and his team had to link priorities to the budget process and use the health budget as a management tool. The ministries of health and finance matched goals and targets to available resources and worked to create actionable plans. And health officials took steps to build cooperation and extend coordination at every level of government in Ethiopia’s federal system. Technical and capacity constraints—plus unexpected political upheaval beginning in late 2015—slowed implementation, but in 2018 a new administration was taking steps to address those challenges.

Gordon LaForge drafted this case study based on interviews conducted in Addis Ababa, Ethiopia, in October 2018. Case published January 2019.

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In 2012, Colombia’s public health system was headed for bankruptcy. The country had made significant progress on important public health priorities: expanding immunizations, reducing infant mortality, and attaining near-universal insurance coverage. But a Constitutional Court ruling that the government had to pay for almost all health services and technologies for those it subsidized, combined with rising pharmaceutical prices, was pushing the budget into deficit. Economist Alejandro Gaviria became minister of health and social protection amid that simmering crisis. To contain spiraling costs while enabling the sector to focus on some of its priorities, he worked to create new legislation that would limit the services the government would cover, regulate the drug market, and adjust an incentive structure that had lowered accountability and encouraged excess. In parallel, budget officials in the health ministry, the Ministry of Finance and Public Credit, and the National Planning Department tried to improve financial management of the system in order to increase efficiency and reduce costs. In the end, some of Gaviria’s efforts paid off and the ministry averted immediate insolvency, but as of 2018, the viability of Colombia’s health-care system remained in doubt even as health indicators improved.

Gordon LaForge drafted this case study based on interviews conducted in Bogota, Colombia in September 2018. Case published November 2018.

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